Surgical treatment of the inferior turbinate for allergic rhinitis: clinical evaluation and therapeutic mechanisms of the different techniques

Abstract

Summary Many different surgical procedures have been described to alleviate nasal obstruction due to turbinate hypertrophy in patients with allergic rhinitis (AR) who continuously have chronic nasal congestion. The goal of surgical procedures should be ‘optimal reduction of volume and secretion with preservation of function’. For a period of about 25 years, laser surgery of the inferior turbinate has been considered a simple and effective surgical treatment with a low complication rate that has been in widespread use by many ENT surgeons. Various trials have demonstrated the clinical effectiveness of a series of different laser systems including carbon dioxide, Nd:YAG, potassium‐titanyl‐phosphate, and diode laser. Laser surgery generally induces significant increases of the total volume of the nasal cavity. Several studies have provided evidence that the expression degree of local inflammatory cytokines and chemical mediators can be attenuated by the treatment. The mucociliary function of the inferior turbinate seems to be preserved after CO2 laser intervention. A breakthrough in the surgical procedures available for allergic patients who severely suffer from both intractable hypertrophic inferior turbinates and unregulated nasal secretion was introduced in Japan. Posterior nasal neurectomy is a novel alternative method in which neural bundles are selectively cut or cauterized from the sphenopalatine foramen. Resection of the posterior nasal nerve at this point enables surgeons to inhibit the parasympathetic nerve function of the nasal mucosa with no troublesome complications such as decrease of lacrimal secretion. The procedure simultaneously provides interruption of the somatic afferent innervation to the turbinate mucosa. Herein we assess the clinical effectiveness of this surgical procedure based on objective and measurable monitoring parameters and discuss the underlying therapeutic mechanisms.

Long-term effect of posterior nasal neurectomy for perennial allergic rhinitis

“…Postoperative rhinorrhea, sneezing, nasal obstruction scores, TNSS, medication scores, and overall nasal symptoms significantly improved in patients with severe perennial AR who underwent PNN compared with the preoperative scores. PNN was first performed by Kikawada et al (2) by cutting parasympathetic nerve fibres and sensory nerve fibres derived from the vidian nerve and the second branch of the trigeminal nerve, respectively, and it has been suggested to be effective in alleviating rhinorrhea and sneezing symptoms (2,3,8). However, PNN has limited effect on nasal obstruction (9).…”

“…As the posterior nasal nerves contain parasympathetic nerve fibres from the vidian nerve and sensory nerve fibres from the second branch of the trigeminal nerve, PNN is effective in reducing rhinorrhea and sneezing (2,3). In addition, nasal obstruction is likely to be reduced by septoplasty and submucosal inferior turbinectomy.…”

Management of Intractable Nasal Hyperreactivity by Selective Resection of Posterior Nasal Nerve Branches

“…Since the posterior nasal nerve runs through the foramen accompanying the vessels, the question of how to best manage the sphenopalatine artery (SPA) has been a matter of debate [ 5 – 7 ]. Resection of the entire neurovascular bundle by using an ultrasonic coagulator or a coblation system is often performed, but concerns remain regarding possible postoperative bleeding and unfavorable changes in the physiological blood supply in the posterior part of the nasal cavity.…”

Longitudinally Excited CO2 Laser

“…At present, a CO2 laser of about 3 W a pulsed CW of (10 -1000 ms and a super pulse of 0.1 -1 ms) is used for the skin treatment such as eliminating a mole, a wart, macule (Gotkin et al, 2009) and wrinkle the aurinasal treatment such as hay fever and allergic rhinitis (Takeno et al, 2009), the eye treatment such as blepharochalasis and droopy eyelid (Rokhsar et al, 2008), and the dental treatment such as section and evaporation of soft tissue, hemostasis, and stomatitis (Zand et al, 2009). The advantages of CO2 laser surgery are alleviation of bleeding, pain and edema, and shortening of operation and recovery time.…”